A Rare Ultrasonographic Finding of Emphysematous Cholecystitis: The Champagne Sign.

BACKGROUND: Emphysematous cholecystitis (EC) is a form of cholecystitis with high mortality rates more commonly seen in patients with medical histories such as diabetes, hypertension, and peripheral vascular disease. The common features of these medical diseases are impaired pain perception, particularly abdominal pain, due to advanced age and peripheral neuropathies. Accurate evaluation of characteristics observed at ultrasonography, the method of first choice in the diagnosis of EC, is therefore highly important in these patients. CASE REPORT: This study reports a case of the champagne sign, rarely seen in EC, together with other EC findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The champagne sign is a little-known sonographic finding that is evidence of the presence of gas in the gallbladder. The champagne sign that will be detected while evaluating the hepatobiliary system on bedside ultrasound is one of the valuable findings in the diagnosis of emphysematous cholecystitis with high mortality.

How would you like your COVID-19? From a host with mild course disease, or from a severe one?

The clinical course of COVID-19 presents a broad spectrum, being asymptomatic in some individuals while following a severe course and resulting in mortality in others. It is known that such factors as age and chronic diseases can result in a different clinical courses in individuals, however, variable clinical courses among the similar individuals in terms of age and chronic diseases are also seen. Other possible factors affecting the course of the disease that are mostly speculative or under investigation are genetic factors and the origin of transmission or possible subtype of novel coronavirus. Whether the source of transmission is important in the clinical course of the disease is unknown. A case series composed of seven individuals in a similar age group, with different lines of descent and different genetic structures, but who were infected from the same source is presented here. The similar and different clinical, laboratory and radiological findings of the cases residing in the same nursing home, who presented to the hospital altogether, were evaluated. The aim of the study was to analyze whether the source of transmission is influential in the clinical course of the disease.

Effect of Changes in Intravascular Volume on Inferior Vena Cava and Aorta Diameters and the Caval/Aorta Index in Healthy Volunteers.

OBJECTIVES: Although inferior vena cava diameter (IVCD) measurement can be useful as a noninvasive method for monitoring the volume status, the benefit of abdominal aorta diameter (AAD) measurement is unclear. The purpose of this study was to determine the value of the combined use of the IVCD and AAD in blood loss monitoring. METHODS: This prospective observational study was conducted at the blood donor center of a training and research hospital. Standard blood donation criteria were followed during volunteer enrollment. Vital signs and ultrasound IVCD and AAD measurements were obtained before and after blood donation and after fluid resuscitation with 500 mL of 0.9% sodium chloride. Measurements before and after blood donation and after fluid resuscitation were compared by the paired t and Wilcoxon matched-pair tests. RESULTS: Thirty-nine volunteers were included in the study. With 500 mL of blood loss, percent changes in the shock index (SI; mean ± SD, 7% ± 6%), IVCD (6% ± 2%), and caval/aorta index (IVCD/AAD; 6.1% ± 3%) were similar and were higher (P < .001 for all parameters) than the changes in the pulse rate (3% ± 4%), AAD (0.5% ± 1.5%), systolic blood pressure (3% ± 4%), and diastolic blood pressure (2% ± 7%). Although IVCD and SI values changed significantly (P < .001 for both) after 500 mL of 0.9% sodium chloride resuscitation, no significant change was observed in the IVCD/AAD (P = .059). CONCLUSIONS: The IVCD/AAD, SI, and IVCD may have similar success rates in diagnosing early blood loss. Additionally, the SI and IVCD may be superior to the IVCD/AAD in bleeding patients requiring simultaneous fluid resuscitation.

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures.

BACKGROUND: The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management. OBJECTIVES: The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED. METHODS: Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction. RESULTS: Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups. CONCLUSIONS: The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.

Evaluation of serum fibroblast growth factor-23 in patients with axial spondyloarthritis and its association with sclerostin, inflammation, and spinal damage.

The mechanisms underlying new bone formation in individuals with axial spondyloarthritis (axSpA) remain unclear; however, low levels of sclerostin (SOST) may be associated with development of syndesmophytes in those with ankylosing spondylitis (AS). Expression of fibroblast growth factor-23 (FGF-23), another osteocyte factor, is high in those with osteoporosis and chronic renal failure, but levels in those with axSpA are unknown. To evaluate serum FGF-23 and SOST levels in axSpA patients, and to assess their relationship with inflammation and structural damage. In total, 109 axSpA patients (55 with AS and 54 with non-radiographic axSpA) and 57 healthy control (HC) subjects were included in the analysis. Serum concentrations of FGF-23 and SOST were measured and correlation analysis was performed. The presence of syndesmophytes and the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) were used to assess structural damage. Levels of serum FGF-23 in axSpA patients were significantly higher than those in HCs [median (interquartile range-IQR) FGF-23 level, pg/ml; AxSpA = 144 (82.3-253.2), HC = 107 (63.3-192.8), p = 0.010]; however, there was no difference in SOST levels. FGF-23 levels correlated with the erythrocyte sedimentation rate (ESR) (r = 0.265, p = 0.006) and serum C-reactive protein (CRP) level (r = 0.229, p = 0.010). In the axSpA, SOST levels correlated negatively with mSASSS (r = - 0.283, p = 0.007), whereas those in the AS group correlated negatively with CRP (r = - 0.426, p = 0.001). Serum FGF-23 levels were high in axSpA patients. Increased FGF-23 was associated with inflammation, but not with SOST levels or disease activity. SOST correlated negatively with both inflammation and structural damage.

A comparison of noninvasive methods for early detection of hemorrhage: Inferior vena cava ultrasonography and spectrophotometric hemoglobin levels.

OBJECTIVES: Blood hemoglobin concentration measurements using a spectrophotometric method (SpHb), and inferior vena cava ultrasonography (IVC-US) are noninvasive methods used to follow-up hemorrhages. We compared their efficacy using voluntary blood donation as a model of moderate (approx. 500 mL) blood loss. METHODS: In this prospective observational study enrolling blood-donor volunteers (BD) and matched controls, we recorded SpHb, IVC diameters, and vital signs. Changes in variables from baseline were compared between BD and controls using the paired t test and Wilcoxon signed rank test. RESULTS: We included 118 subjects in the BD group and 95 healthy subjects in the control group. Changes in IVC maximum diameter, IVC minimum diameter, pulse rate, mean arterial pressure, pulse pressure, and shock index, but not in other variables, were significantly different in the BD and the control group (P < 0.05). IVCmax ≥1.1 mm yielded a 74% sensitivity and 77% specificity (PPV 79.8%, NPV 70.2%) in detecting early hemorrhage. With these cutoff values, IVCmax or PR reached a 90% sensitivity, while IVCmin and PR reached 98% specificity. CONCLUSIONS: IVC ultrasound may be superior to SpHb in predicting blood loss and may be useful in addition to vital signs for its follow-up.

Euglisemic diabetic ketoacidotic coma caused by dapagliflozin.

Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening acute complication of diabetes mellitus (DM). Sodium-glucose co-transporter-2(SGLT-2) inhibitors are new orally administered antihyperglycemic agents. These agents are related with rarely seen euglycemic diabetic ketoacidosis (eDKA) cases, which are difficult to diagnose in emergency department (ED) because of absence of an evident hyperglycemia and may result with potentially dangerous outcomes if missed. In this study, we present a clinical case of a patient, admitted to ED with altered mental status after SGLT2 inhibitor dapagliflozin administration.

A rare cause of dyspnea in emergency medicine: transfusion-related acute lung injury.

The earliest definition of transfusion-related acute lung injury (TRALI) included all patients who developed acute respiratory distress, moderate to severe hypoxemia, rapid onset of pulmonary edema, mild to moderate hypotension, and fever within 6 hours of receiving a plasma containing blood transfusion. The definition excluded patients if they had underlying cardiac or respiratory disease. The mechanism is not known exactly but it causes morbidity and mortality. Incidence of TRALI changes between 0.08% and 15% of patients receiving a blood transfusion. A 78 year old female patient with history of myelodysplastic syndrome, coronary artey disease and hypertansion, was admitted to the hospital because of dyspnea after the blood transfusion. She was managed as TRALI after diagnostic workup and transported to the intensive care unit. In the following days her clinical status changed dramatically with complete recovery.

Red cell distribution width in patients with prehypertension and hypertension.

OBJECTIVE: Red cell distribution width (RDW) which is reported as part of complete blood count in routine clinical practice, is a measure of variability in size of the erythrocytes in the circulation. It is a novel predictor of mortality both in unselected populations and in some selected group of patients. We aimed to search whether RDW values differ between the healthy population and the patients with pre-hypertension and hypertension who are otherwise healthy, considering the widely accepted role of RDW as a prognostic marker especially for mortality. PATIENTS AND METHODS: Patients who were diagnosed with prehypertension or hypertension for the first time according to the Joint National Committee (JNC) 7 criteria and otherwise healthy were enrolled to the study. One-hundred and twenty-eight patients with hypertension, 74 patients with prehypertension and 36 healthy controls participated in the study. Complete blood count, biochemistry and erythrocyte sedimentation rates were measured by standard methods. Hemoglobin, white blood cell count, mean corpuscular volume, platelet count and RDW were recorded. RESULTS: After adjustment for age, hemoglobin level, presence of anemia, serum uric acid level, erythrocyte sedimentation rate and mean corpuscular volume, mean RDW values were 15.26 ± 0.82, 16.54 ± 0.91 and 13.87 ± 0.94 in prehypertensive, hypertensive and control groups, respectively (p < 0.05). Systolic and diastolic blood pressures were strongly correlated with RDW (r = 0.848 and r = 0.748, respectively; p < 0.01). CONCLUSION: RDW is higher in prehypertensive and hypertensive patients compared with healthy controls independently of age, inflammatory status and anemia. Higher RDW values are strongly correlated with higher systolic and diastolic blood pressures.

A rare complication of cardiopulmonary resuscitation applied during transportation by ambulance: A case report of flail chest.

Cardiopulmonary resuscitation (CPR) to be applied during patient transfer by ambulance differs from CPR applied in the field or in the hospital in terms of physical condition. Especially the deeper and faster chest compressions recommended in the latest CPR guidelines, when administered during ambulance transport, may result in a further increase in traumatic CPR complications. However, in the current CPR guidelines, there are no clear recommendations regarding additional measures that can be taken to reduce the complications and increase the efficiency of CPR during patient transport. In this study, a case of flail chest that developed after short-term CPR application during ambulance transport is presented. The aim of this study was to evaluate the flail chest complication and solution suggestions that may occur due to chest compressions applied during transportation.

Evaluation of an artificial intelligence system for diagnosing scaphoid fracture on direct radiography.

PURPOSE: The aim of this study is to determine the diagnostic performance of artificial intelligence with the use of convolutional neural networks (CNN) for detecting scaphoid fractures on anteroposterior wrist radiographs. The performance of the deep learning algorithm was also compared with that of the emergency department (ED) physician and two orthopaedic specialists (less experienced and experienced in the hand surgery). METHODS: A total 390 patients with AP wrist radiographs were included in the study. The presence/absence of the fracture on radiographs was confirmed via CT. The diagnostic performance of the CNN, ED physician and two orthopaedic specialists (less experienced and experienced) as measured by AUC, sensitivity, specificity, F-Score and Youden index, to detect scaphoid fractures was evaluated and compared between the groups. RESULTS: The CNN had 76% sensitivity and 92% specificity, 0.840 AUC, 0.680 Youden index and 0.826 F score values in identifying scaphoid fractures. The experienced orthopaedic specialist had the best diagnostic performance according to AUC. While CNN's performance was similar to a less experienced orthopaedic specialist, it was better than the ED physician. CONCLUSION: The deep learning algorithm has the potential to be used for diagnosing scaphoid fractures on radiographs. Artificial intelligence can be useful for scaphoid fracture diagnosis particularly in the absence of an experienced orthopedist or hand surgeon.

Holistic Analysis of Coronavirus Literature: A Scientometric Study of the Global Publications Relevant to SARS-CoV-2 (COVID-19), MERS-CoV (MERS) and SARS-CoV (SARS).

OBJECTIVES: In late December 2019, a cluster of patients with pneumonia caused by an unknown pathogen was reported from Wuhan, Hubei Province, China. The pathogen has been identified as a novel coronavirus, severe acute respiratory syndrome 2 (SARS-CoV-2) and the disease has been named as coronavirus disease 2019 (COVID-19). The objective of this study was to perform the first holistic scientometric evaluation of coronavirus publications. METHODS: Our main source for this study was Web of Science Collection database. All items published between 1980 and 2019 were included. A distribution map of global production in coronavirus literature and scientometric networks were generated. RESULTS: The United States, China, Germany, the United Kingdom, and Netherlands were the most productive countries. Publications in coronavirus literature have been produced from almost every country in the world, except for some countries in Asia and Africa. CONCLUSION: While in the 1980s, the United States and developed countries from Europe were major source countries and the virus was identified only as an animal disease in the literature and its biological and genetic structure was investigated, in the 2000s, China became a major contributor of coronavirus literature because the SARS outbreak originated from southern China. Almost all most-cited publications in this period are related to SARS and the ACE2 protein.

A rare complication of continuous positive airway pressure treatment - rectus sheath hematoma: a case report.

Noninvasive mechanical ventilation (NIMV) has a relevant role in the treatment of critically ill patients displaying severe dyspnea. Continuous positive airway pressure (CPAP), a method of NIMV, is also widely used in the management of acute heart failure, chronic obstructive pulmonary disease (COPD) exacerbation, and symptomatic sleep apnea. However, numerous traumatic complications of CPAP treatment in the face region, head, and thorax have been reported and may be related to the application of a continuous positive high pressure to the airway. Conversely, we have observed no complications due to CPAP-related increased intra-abdominal pressure. In this article, we describe a clinical case of a patient with an acute rectus sheath hematoma during CPAP treatment. This previously unreported complication demonstrates that CPAP should be carefully used in patients with exacerbated COPD with difficulty in expiration.

Relationship between a Prolonged Corrected QT Interval and Mortality in Patients Presenting with Syncope at the Emergency Department.

BACKGROUND: Syncope is a common symptom in emergency department patients. Among various etiological factors, cardiac causes have the highest risk of mortality. The corrected QT interval is considered an independent predictor of mortality for many diseases. OBJECTIVES: Analyze QT interval analysis of patients presenting to the emergency department with syncope. METHODS: In this prospective observational study, patients who presented to the emergency department with syncope between January 1, 2018, and January 1, 2019 were included. RESULTS: The median age was 64 (49-78) years, and 58.8% of patients were male. The corrected QT interval (QTc) in patients with coronary artery disease and chronic obstructive pulmonary disease was longer than those without. There was no statistically significant association between hypertension, diabetes, stroke, thyroid disease, and prolonged QTc. Patients who did not survive had significantly prolonged QT intervals. According to ROC analysis, sensitivity of >440.5 ms QTc values in predicting mortality was 86% and specificity was 71% (AUC = 0.815; 95%CI = 0.71 - 0.91; p < 0.001). CONCLUSIONS: Patients admitted to emergency department with syncope and a prolonged QTc are associated with a higher mortality rate and thus can provide us with an important guide for the management of these patients.

Prevalence of pistol-grip deformity in patients with axial spondyloarthritis.

OBJECTIVE: To our knowledge, the prevalence of pistol-grip deformity (PGD) has not previously been studied in patients with axial spondyloarthritis (axSpA). This study aimed to evaluate PGD prevalence in patients with axSpA and to assess its relationship with the clinical and demographic factors. METHODS: A total of 158 patients with axSpA in whom diagnosis was established according to the Assessment of SpondyloArthritis International Society criteria in rheumatology department and 193 age- and sex-matched controls admitted to the emergency room and had anteroposterior (AP) pelvic X-rays were included in the study. PGD was identified by determining the non-spherical shape of the femoral head on AP hip or pelvic X-rays. RESULTS: Prevalence of PGD was significantly higher in patients with axSpA than in controls (20.3% vs. 8.8%, respectively, p=0.002). PGD was also found to be more frequent in patients with radiographic axSpA than in those with non-radiographic axSpA (26/106 [24.5%] vs. 6/52 [11.5%]); however, this difference did not reach statistical significance (p=0.056). The presence of PGD was significantly associated with the presence of hip arthritis (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-8.7; p=0.023), ever smoking (OR, 4.5; 95% CI, 1.4-13.6; p=0.008), and male sex (OR, 38.7; 95% CI, 5.1-292.7; p<0.001) in univariate analyses. In multivariate model, ever smoking (OR, 2.9; 95% CI, 1.10-10.05; p=0.03) and male sex (OR, 27.0; 95% CI, 3.5-208.4; p=0.002) were associated with PGD. CONCLUSION: PGD was significantly more common in patients with axSpA. Presence of PGD correlated significantly with hip arthritis, smoking, and sex. We assume that new bone formation could be the possible reason for increased PGD prevalence. Femoroacetabular impingement should be considered as a secondary cause of hip pain in patients with axSpA.

The value of conventional manometry in the identification of normal esophageal manometry.

ABSTRACT: In the last decade, high-resolution esophageal manometry (HREM) is the main device for the management of dysphagia replacing conventional manometry (CM). Conventional manometry still seems to have some space to diagnose major motility disorders and differentiate normal from abnormal esophageal motility. The long term outcomes of patients with normal CM were analyzed in our study.Participants (patients with dysphagia and normal CM) took a questionnaire via a phone call in February 2021. Impact Dysphagia Questionnaire (IDQ) was used as an assessment tool.Only 55% (83/151) the individuals with previous normal manometric findings were reached via telephone. The group who have completed the survey was representative of the cohort. 66.2% of the participants were female (P = .40). The mean age was 57.21, mean weight was 70.69 kg, mean height was 163.74 cm and mean body mass index was 26.41. More than 40% of patients were completely asymptomatic at follow up, reflected by an IDQ score of 0. Only 28 out of 83 (33.7%) patients reported significant symptoms as reflected by an IDQ score greater than or equal to 7. The rest of responders admitted as having moderate to mild symptoms.HREM is a valid technique with comparable precision to CM. HREM measurements differ considerably to CM. The identification of normal motor function in CM is not likely a positive prognostic indicator and must be interpreted precautiously.

The effect of bovine serum albumin-glutaraldehyde and polyethylene glycol polymer on neointimal hyperplasia in rabbit carotid artery anastomosis.

OBJECTIVE: Since the systemic drugs have been used to reduce the hyperplasic response in the tunica intima, the periadventitial local drug applications to the vascular wall have gained more popularity. In this study, we investigated the effect of bovine serum albumin-glutaraldehyde and polyethylene glycol polymer on neointimal hyperplasia in rabbit carotid artery anastomosis to explore the effects of these two different agents. METHODS: 21 New Zealand male rabbits were randomly divided into three groups. The carotid artery transection and anastomosis was performed onthe control group. The bovine serum albumin-glutaraldehyde and the polyethylene glycol polymer were applied locally on the other two groups seperatley after transection and anastomosis of the carotid arteries. At the end of 28-day follow-up, the histological and the immunohistochemical results related to neointimal hyperplasia were compared. RESULTS: The glue residues were detected in the BSA-glutaraldehyde group, but in the PEG polymer group there was no glue residue. The intima thickness and the intima/media thickness ratio in the control group was significantly higher (p<0.05) than the other groups. These values did not differ significantly between the BSA-glutaraldehyde group and the PEG polymer group (p>0.05). The lumen diameter and the area in the control group were significantly higher (p < 0.05) than the BSA-glutaraldehyde group. These values between the control group and the PEG polymer group did not differ significantly (p>0.05). aSMA-positive staining score in the Control group was found to be significantly lower (p < 0.05) than the BSA-glutaraldehyde and PEG polymer group and the VEGF-positive staining score in the control group was found to be significantly higher (p < 0.05) than the BSA-glutaraldehyde and the PEG polymer group. CONCLUSIONS: Although the both agents have positive results on neointimal hyperplasia, it would be favorable to use polyethylene glycol polymer, since it does not seem to affect the lumen area and the lumen diameter of the vessel.

Portal Hypertensive Polyps as Gastroscopic Finding in Liver Cirrhosis.

BACKGROUND: Portal hypertensive polyps in patients with portal hypertension are described. AIMS: The most significant and serious complication in liver cirrhosis proves to be portal hypertension. Polypoid lesions, which can be seen in the stomach as endoscopic finding in patients with portal hypertension, have not quite been defined in the literature. The aim of this study, therefore, was to define polypoid lesion formation due to portal hypertension in the upper gastrointestinal system in patients with portal hypertension. Study Design. Cross-sectional study. METHODS: The study covered a group of patients with liver cirrhosis and a healthy control group that did not have portal hypertension. All individuals covered by the study received upper GI endoscopy, while the endoscopic features and pathological characteristics of the identified polypoid lesions were defined. Standard histological criteria were used in polyp diagnosis. RESULTS: A total of 400 individuals were included in the study. Upper GI endoscopy was performed for 200 patients with liver cirrhosis and another 200 healthy individuals with no portal hypertension in the control group. When the cases were gastroscopically assessed with regard to polypoid lesion presence, it was seen that a total of 87 (21.8%) individuals had polyps. While 67 (33.5%) cirrhotic patients were identified to have polyps, 20 (10%) individuals in the healthy control group had polyps. When the results of those with liver cirrhosis who received esophageal variceal endoscopic band ligation (EVL) and who did not were compared, it was observed that a higher number of individuals in the group with EVL had polypoid lesions. When the patient and control groups were compared as to Helicobacter pylori presence, the results showed that it was slightly higher in the dyspepsia group but the difference was not statistically significant (p > 0.05). CONCLUSION: Portal hypertension-associated polypoid lesions are common in advanced liver cirrhosis cases. The pathological analyses of these polyps pointed out that they were all benign and no malignant cases were detected. It was argued that these polypoid lesions, referred to as portal hypertensive polyps, were associated with elevated angiogenesis in the gastric mucosa.

A case of luftsichel sign for left upper lobe collapse.

The differential diagnosis of dyspnea in Emergency Department (ED) patients is broad and atelectasis is one of the differentials among these. We present a 29-year-old women presented to our ED for evaluation of shortness of breath. On her chest examination, air entry and breath sounds were diminished on the left side but normal on the right. A posteroanterior chest radiograph showed radioluscent area in the upper zone of the left lung, around the aortic arch and also hyperdens area neighbouring this, like covered by a veil. Luftsichel sign together with this hiperdensity were consistent with the diagnose of left lung upper lobe collapse. The Luftsichel sign represents the hyperexpanded superior segment of the left lower lobe interposed between the atelectatic left upper lobe and aortic arch. Patient was discharged to home with chest physiotherapy and breathing exercises together with analgesic prescreption.